A Totally Substandard Beat-up.
P2 - Err WTD? - I would have thought the greater 'safety issue' was the fact the crew missed resetting the altimeters to actual local QNH - Just saying.
Aye, ‘tis a big no-no – however I think this is a ‘classic’ Reason model case and probably a good report to have in the library to demonstrate just how very easy it is, even for experienced crew to fall into a ‘trap’.
My ‘Jepp’ chart series for Kosrae is well out of date, but it will serve for now. One of the first things you note is no ATIS, the next is the rather oblique statement – “ Trans level by ATC” followed by (Trans Alt : by ATC). This may have changed since my chart was published; but ATSB make no mention of the stated ‘transition altitude’ in effect at the time. This is an important ‘trigger’ prompting an almost instant reflex action - write the setting on the TOLD card – set the local barometric reading on the Altimeter and cross check. It’s a curiosity only, but say the crew habitually used F 130 as ‘transition’ from flight levels to barometric altitude, but were obliged to remain on the 1013 datum to almost the beginning of the approach – (traffic separation?) you still must wonder why the approach checks were not complete by then – even if there was a low transition. Has human factors and fatigue played a big role in this little drama? ATSB make no mention of the duty period or the flight schedule so it’s hard to quantify how much that element of the causal chain is attached to the incident. The ultimate message is clear enough but the bare facts, as presented, fail to provide insight as to why a routine, deeply ingrained almost habitual action was not completed by an experienced crew.
The next item is the approach itself. ATSB cite it as being a ‘dive and drive’ event; this is grossly misleading. The profile chart is drawn using ‘step’ down; but its not flown in the manner depicted – ATSB should know this. D&D was outlawed by serious operators years ago, with bloody good reason. The D&D method is not only potentially lethal, but inefficient and ‘unstable’. ATSB hint that the crew hung about at 1500 feet then ‘dive’ to the next limiting height and ‘drive’ up to the next descent point – Bollocks. Do that in any ‘performance’ aircraft – let alone a swept wing jet and you are looking for trouble. I digress.
On my old chart the NDB approach is ‘tight’ – the approach path points directly at an 800 foot high chunk of terra firma; and, leaves you at 2.9 miles to conduct a visual circling approach; except there is no circling permitted South of runway 05 or 23. A 76 ton aircraft at 130 knots inside of three miles, in the dark, pissing rain with nothing but rising terrain ahead – off a ‘D&D’ style of approach – Nah; don’t think so. Lets’ take a look at my old chart again. At 10 miles almost due West of the hills (797’ terrain @ 7200 [6080’ = ONE nautical mile = 30 seconds at 120 knots] feet ESE of the airport) the NDB approach begins at 1500’ AMSL; that leaves 5 miles to run to the IAF at 900’ – at 140 knots a rate of descent :: to 700 fpm is stable and easily do-able. This fetch’s the aircraft to five miles and enough room to break left or right and join the circuit. So to a visual night circuit, in the rain, think about it for a moment. To land 05 the crew loose sight of the runway – (break right) - left turn to pick up a three mile final – acceptable. To make final leg on the 23 direction is almost unacceptable; a long left turn, followed by a right to base followed by another right hander to final – the runway out of sight until base leg to the FO and out of sight to the Capt. until late base/ final. Not a 'visual approach' at all.- Not too bad in good conditions – but tricky in bad.
Ah well; at least the GPS approach system and equipment is available to use now. A straight in runway approach to 5/600 feet is right and proper for heavy jet transport in this day and age. Most sensible. What is not acceptable is the ATSB dumbing down and presenting, in bad English, a valuable safety lesson.
ATSB – “This resulted in the aircraft’s altitude being lower than what the pressure altimeter was indicating to the pilots.” – Seriously, who writes and edits this crap?
Right – back to my knitting.
Toot – toot.
P2 - Err WTD? - I would have thought the greater 'safety issue' was the fact the crew missed resetting the altimeters to actual local QNH - Just saying.
Aye, ‘tis a big no-no – however I think this is a ‘classic’ Reason model case and probably a good report to have in the library to demonstrate just how very easy it is, even for experienced crew to fall into a ‘trap’.
My ‘Jepp’ chart series for Kosrae is well out of date, but it will serve for now. One of the first things you note is no ATIS, the next is the rather oblique statement – “ Trans level by ATC” followed by (Trans Alt : by ATC). This may have changed since my chart was published; but ATSB make no mention of the stated ‘transition altitude’ in effect at the time. This is an important ‘trigger’ prompting an almost instant reflex action - write the setting on the TOLD card – set the local barometric reading on the Altimeter and cross check. It’s a curiosity only, but say the crew habitually used F 130 as ‘transition’ from flight levels to barometric altitude, but were obliged to remain on the 1013 datum to almost the beginning of the approach – (traffic separation?) you still must wonder why the approach checks were not complete by then – even if there was a low transition. Has human factors and fatigue played a big role in this little drama? ATSB make no mention of the duty period or the flight schedule so it’s hard to quantify how much that element of the causal chain is attached to the incident. The ultimate message is clear enough but the bare facts, as presented, fail to provide insight as to why a routine, deeply ingrained almost habitual action was not completed by an experienced crew.
The next item is the approach itself. ATSB cite it as being a ‘dive and drive’ event; this is grossly misleading. The profile chart is drawn using ‘step’ down; but its not flown in the manner depicted – ATSB should know this. D&D was outlawed by serious operators years ago, with bloody good reason. The D&D method is not only potentially lethal, but inefficient and ‘unstable’. ATSB hint that the crew hung about at 1500 feet then ‘dive’ to the next limiting height and ‘drive’ up to the next descent point – Bollocks. Do that in any ‘performance’ aircraft – let alone a swept wing jet and you are looking for trouble. I digress.
On my old chart the NDB approach is ‘tight’ – the approach path points directly at an 800 foot high chunk of terra firma; and, leaves you at 2.9 miles to conduct a visual circling approach; except there is no circling permitted South of runway 05 or 23. A 76 ton aircraft at 130 knots inside of three miles, in the dark, pissing rain with nothing but rising terrain ahead – off a ‘D&D’ style of approach – Nah; don’t think so. Lets’ take a look at my old chart again. At 10 miles almost due West of the hills (797’ terrain @ 7200 [6080’ = ONE nautical mile = 30 seconds at 120 knots] feet ESE of the airport) the NDB approach begins at 1500’ AMSL; that leaves 5 miles to run to the IAF at 900’ – at 140 knots a rate of descent :: to 700 fpm is stable and easily do-able. This fetch’s the aircraft to five miles and enough room to break left or right and join the circuit. So to a visual night circuit, in the rain, think about it for a moment. To land 05 the crew loose sight of the runway – (break right) - left turn to pick up a three mile final – acceptable. To make final leg on the 23 direction is almost unacceptable; a long left turn, followed by a right to base followed by another right hander to final – the runway out of sight until base leg to the FO and out of sight to the Capt. until late base/ final. Not a 'visual approach' at all.- Not too bad in good conditions – but tricky in bad.
Ah well; at least the GPS approach system and equipment is available to use now. A straight in runway approach to 5/600 feet is right and proper for heavy jet transport in this day and age. Most sensible. What is not acceptable is the ATSB dumbing down and presenting, in bad English, a valuable safety lesson.
ATSB – “This resulted in the aircraft’s altitude being lower than what the pressure altimeter was indicating to the pilots.” – Seriously, who writes and edits this crap?
Right – back to my knitting.
Toot – toot.